All About Pap Smears

All About Pap Smears is presented in the spirit of sharing knowledge and information; all people deserve to know about their bodies and how they work. This piece is dedicated to Henrietta Lacks and her family. If you have never heard of her, please read here. I cannot recommend the book, The Immortal Life of Henrietta Lacks, enough and believe it should be required reading for all people interested in the sciences, health care and bioethics.

One of the most common sources of confusion that I encounter among my clients is surrounding the pap smear. Often, folks don’t know why they are done, how they are done or how important they are. Many clients I have counseled believe that anything “done down there” is a pap smear. The complete lack of education given to clients by many health care professionals is mind boggling. I do not blame my clients for their lack of understanding and I enjoy the opportunity to provide education. The bottom line, or take home message, should be pap smears save lives! At the beginning of the 20th century, cervical cancer was the highest cause of cancer deaths for women and now with screening, it doesn’t even rank in the top 10.Also, even though the new cervical cancer screening guidelines have changed (which is reviewed below), this does not mean that annual well woman exams are not necessary….a pap smear is not the only reason to be seen regularly.

Anatomy of the Cervix

The cervix, usually about 2cm in length, is the lower region of the uterus and serves to connect the vagina to the uterus. It is made up primarily of connective tissue and has several different areas of various cell types. The endocervical canal runs through the cervix. The vaginal opening is referred to as the external os, while the opening to the uterus is called the internal os. The endocervical canal is lined with columnar cells, these are a type of glandular cell that secrete mucous. This pathway is where menstrual blood is released from the uterus and where seminal fluid and sperm are transported through to the womb. The cervix is strong enough to hold in and contain the contents of the uterus during the growing demands of pregnancy and then soft enough to allow the uterus to open and allow the birth of the baby and placenta.

The portion of the cervix visible through the vagina is known as the ectocervix. The ectocervix is comprised of squamous cells, these are flat scale-like cells that are continually renewing, growing and changing throughout the course of a woman’s life. Where the endocervical columnar cells overlap with the ectocervial squamous cells is an area referred to as the transitional zone. This zone, due to the cell type, is where the majority of cervical cancers will originate.

Cervical Cancer: what, how and why

Over 99% of Cervical Cancer is caused by the sexually transmitted Human Papillomavirus (HPV). There are over 100 strains of HPV and most are considered low risk for leading to cervical cancer. Low risk strains are associated with genital warts. The rates and severity of cervical cancer increase with age and are rare in women under 30. With screening, the current rate of cervical cancer in the US has declined to roughly 7 out of 100,000 women.

The cervix has two main cell types that may develop cancer. The squamous cells found in the ectocervix and the glandular cells found in the endocervical canal. Squamous cell carcinoma (SCC) is responsible for almost all cases of cervical cancer, and occurs in the transition zone of the ectocervix. Adenocarcinoma is responsible for 10-20% of cervical cancer and occurs in the glandular cells of the endocervical canal.

Unfortunately, there are no outward or noticeable symptoms of cervical cancer until the disease has progressed to a severe level, this is why routine screening is critical. Symptoms of advanced cervical cancer are abnormal vaginal bleeding and discharge, pelvic and abdominal pain and pain with intercourse.

All About the Pap

The Papanicolaou (pap smear) test was introduced to widespread use in the 1950’s and since its introduction, the incidence of cervical cancer deaths in developed nations has dropped up to 70%. The pap smear is the most effective cancer screening test available. During a pap smear, a small sample of cervical cells are taken from the cervical opening or external os. These cells are then sent to a lab for cytology testing; to screen for abnormal cellular growth. Additional testing screens for the presence of HPV. So, there are essentially two tests; the cytology testing or analysis of the cells and the test to assess HPV status. In 2012, the new guidelines for the pap smear screening were released and they were a significant change in practice. The change was made with new understanding of the progression of the disease and to decrease the rates of invasive procedures that were not improving outcomes. The guidelines were released by three organizations; The American Society for Colposcopy and Cervical Pathology (ASCCP), The American Cancer Society (ACS) and the American Society of Clinical Pathology (ASCP) .

Screening Guidelines

Begin universal screening of all women at age 21, regardless of onset of sexual activity.

Ages 21-29; cytology screening alone every three years.

Ages 30-64; cytology screening + HPV testing (co-testing) every five years. If co-testing is unavailable, cytology testing alone every three years is acceptable.

Age 65 and older; may stop screening if has a history of either three consecutive negative cytology screens or two consecutive negative HPV tests.

Post hysterectomy: if the cervix is also removed and there is no history of CIN2 or higher within the previous 20 years or cervical cancer ever, then screening is no longer required.

Result Types

Normal: based on the analysis of the cells there are no abnormal changes suspicious of cancer or pre-cancerous changes.

ASC-US or Atypical Squamous Cells of Undertermined Significance: this is actually an inconclusive result, it means that the cells sampled don’t look normal but they also don’t look abnormal, weird right? It can be a frustrating result to receive. Three quarters of folks with this result will NOT have abnormal cells with further evaluation.

Abnormal results:

Low-Grade SIL (LSIL) or CIN 1 are mildly abnormal squamous cells that usually resolve on their own.

High-Grade SIL (HSIL), CIN2 or CIN3 are moderate to severely abnormal squamous cells. These cellular changes are strongly linked with a higher risk of becoming cancerous or may mean that there is already underlying cancer. CIN3 may also be called carcinoma in situ, this is an early stage of cancer where tumor cells have not yet invaded surrounding tissue.

HPV results are reported as positive or negative and can be further divided by particular strain of the virus, such as 16 or 18 which are the strains most at risk to develop cervical cancer.

Atypical Glandular Cells (AGC) are abnormal glandular cells, the type found in the endocervical canal.

Adenocarcinoma in Situ (AIS) are pre-invasive cancer cells found in the endocervical canal.

Management of Results

When you receive the results of a pap smear, your health care provider should discuss them with you. In deciding what to do with inconclusive or abnormal results, your choices should be honored and recognized as an integral part of the plan. Additionally, your individual previous health history and current situation should be factored in.

Depending on these factors, the choice may be made to offer follow up testing to gain more information, the first one of these tests is a Colposcopy . This is a relatively simple test that allows your provider to take a closer look at your cervix to determine if there are any cells or areas of cells that look abnormal. If abnormal cells are seen a sample of them, or biopsy, will be collected and sent to a lab for further testing. Based on the results of the biopsy, additional treatments may be recommended. You can read more about these here.

My Pet Peeves

When you go to a provider for any type of visit, you deserve and should expect to be treated with respect and dignity. All procedures should be explained to you and all of your questions should be answered to your satisfaction. Any abnormal results should be explained in detail as well as any recommended follow up testing and plan of care. If this is not your experience, demand better; ask questions and if possible consider finding a new provider.

When getting a pap smear, be sure that your provider uses lubrication on the speculum. The sensitivity of the tests has increased dramatically over the years, and a little bit of gel will not interfere with the results. Not using lubrication can significantly increase the discomfort of the procedure. I always use a small amount of gel and rarely have results that are “unreadable”.

Not all speculums are created equally! They come in different sizes. In my experience, I can almost always do a speculum exam and collect a pap smear with the “smaller” Pederson over the “larger” Graves. The photo below gives you a size comparison, with the Pederson on the left and the Graves on the right. Clearly, the smaller speculum will likely cause less discomfort. It is well within your rights to request the smaller size if you feel it will be less traumatic for you.

I hope this information is informative and helpful. Do you have any other questions or thoughts? Please feel free to share and ask them here.

Resources

An amazing, empowering website with all the visuals you could ever hope for. The Beautiful Cervix Project shares real photos of cervices, so be prepared before exploring. One of my favorite parts of the website is the Self-Exam Kit that can be purchased so you can get to know your own cervix in the privacy of your home.

A fantastic resource for the concept of an empowering gynecologic exam can be found on the website of the Feminist Midwife. I highly recommend checking out the rest of her website after reading this piece.

I have already shared my some of my thoughts on the speculum and pelvic exams in, Tools Of My Trade #7 and I invite you to read them as well as this piece.